Prenatal Care Checklist

Preconception

• Folate supplementation- 0.4-1mg/d (1-4mg/day if on seizure meds, twins, DM) 4mg per day if prior pregnancy with neural tube defect
• No tobacco,ETOH,recreational drugs--use dates of cessation on problem list rather than "stopped one month ago" ?recommend vit C if smoking
• Optimize medical problems-(DM, thyroid,anemia,etc) DM A1c goal < 7
• Review medications (avoid statins, ACE inhibitors, Depakote, etc)
• Lab- HbA1c, rubella, RPR, HbsAg, HIV

First visit

• Review healthy start intake-particularly narrative summaries
• Review PNC labs
• History addressing risk factors especially prior obstetric history (verify and correct Healthy Start info)
• Clarify and correct medication list and problem list
• Exam –include cervix/uterine size, breast exam (discuss breastfeeding)/ dating sono if possible
• Obtain outside prior OB records-ie op notes
• Assign gestational age/ EDC

• Send GC, Chlamydia, PAP if needed
• Send wet mount, KOH only if symptomatic or history of preterm delivery
• Baselines labs if pregestational HTN, DM (creat/pro ratio, ALT,AST, creat,) -- can usually be deferred to next scheduled lab draw
• HbA1c > 6.5 dx GDM suspect DM2; 5.7-6.4 do 2 hour GTT or Dx GDM if history consistent (prior macrosomia or GDM2); < 5.7 consider GTT if still concerned for early GDM e.g. prior GDM2.
• Hgb electrophoresis- MCV<70 or African, Asian, Mediterranean ethnicity
• Quantiferon if prior pos untreated TST, out of US/Canada > 1 month in last 5 years, in jail, using street drugs or homeless in last 2 years

• Prior spontaneous preterm birth- consider progesterone caproate (Makena) 250mg IM weekly starting at 16 wks till 36 wks Decreases risk by 1/3. Strongly recommend if < 34 weeks, conside/offer if 34-36 weeks
• H/O cervical incompetence or suggestive loss 15-24 weeks- consider cerclage 12-14 wk gestation after sono--discuss with OB Attending
• Consider perinatology/ high risk pregnancy consult complicated medical or obstetrical conditions
• Flu vaccine
• 1st trimester genetic testing/NT/CVS if appropriate

• Toxin/teratogen avoidance-ETOH, smoking, drugs, OTC/Rx meds, hot tubs, fever, raw meats, cat litter boxes, soft cheese
• Work, exercise, sexual activity, wgt gain, prenatal vits/folate/iron,
• Domestic violence, seat belts
• Pregnancy symptoms- nausea, constipation, leg cramps, back ache

• Consider genetic counseling ( AMA->35yr at delivery (33 yr for twin gestation), pregest DM, prior anomaly)
• Consider level II sono- DM2 or HbA1c > 6.5, AMA > 35 at EDD
• Colpo referral if abn pap with HGSIL or worse
• Order anatomy ultrasound for 18-20 weeks

• Offer second trimester screen. Does not need to have done the NT or first trimester screen. Adds neural tube screening to earlier tests.

• ?shielded CXR if Quantiferon is positive ( 2nd trimester)

• Fetal echo- pregestational DM HbA1c > 8 CHO referral to cardiology/ PA needed for CCHP

• PTL precautions/ diet-- increase protein, vegetables and water with increase in appetite--not just carbs
• 1 hr GTT (24-28wk), repeat CBC; substitute HbA1c for GTT if already GDM or DM
• Sign PPTL consent if desired (good for 6 months, needs 30 days before EDD)

• Instruct in kick counts/Preeclampsia symptoms
• Tdap 27-36 weeks to prevent neonatal pertussis (whooping cough--give every pregnancy even if received recently
• Rhogam if Rh negative (type and screen will be drawn to r/o sensitization and Rhogam given before results)
• Follow FH’s -consider follow up sono if lagging > 2cm
• Consider ordering 32-34 week growth sono if fiboids or maternal BMI makes FH difficult
• VBAC discussion--give handouts and consent to review
• Order repeat limited sono if low lying placenta or previa earlier

• Sign PPTL consent if desired
• Postpartum contraception options discussion if no PPTL (Nexplanon can be placed postpartum, IUD during repeat cesarean)
• Review kick counts

• Consider need for antepartum testing (DM2, GDM2, IUGR, prior loss, etc)
• Schedule elective repeat section if desired ( >39 wk EGA)
• Discuss breastfeeding
• If reports itching without rash order bile acids and begin antepartum testing pending results

34 wks

• Repeat HIV, RPR, CBC, consider HbA1c if DM, GDM
• Schedule elective repeat section if desired ( >39 wk EGA) ?tubal consent make sure consent done correctly, if desired
• Order EFW to be done at 38-39 weeks if DM/GDM and any concern for macrosomia

• GBS culture (36-37 weeks best unless concern for early delivery)
• Position check- consider version referral if non vertex-call L and D 55608 to schedule at 37 weeks
• Labor precautions
• ?State Disability available preg beyond 36 wks
• Consider delivery plans elsewhere if significant fetal anomalies, placenta accreta, maternal cardiac condition, triplets ...
• Induction at 37 weeks for cholestasis, gestational hypertension, preeclampsia without severe features

• Induction for OB indications e.g. prior demise, chronic HTN 38 weeks, GDMA2/DM2 39 weeks

• Start biweekly NST testing/ weekly AFI
• Schedule induction TBD 41w0d to 41w6d

• CXR for + quantiferon if not done in 2nd tri- consider INH
• Contraception discussion
• 6 wk pap vs f/u colpo if initially done in pregnancy for abn pap
• 6 wk 75gm GTT if GDM or HbA1c at 2-3 months or use glucometer to monitor for FBS > 120
• Address breastfeeding issues, screen for depression